Provider Demographics
NPI:1730112954
Name:GRAHAM, MARY LYNN (AUD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:MARQUETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1316 ROCK CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-3278
Mailing Address - Country:US
Mailing Address - Phone:304-264-8884
Mailing Address - Fax:304-264-8885
Practice Address - Street 1:1316 ROCK CLIFF DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-3278
Practice Address - Country:US
Practice Address - Phone:304-264-8884
Practice Address - Fax:304-264-8885
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA-0095237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0160567000Medicaid
WVMA0795852Medicare ID - Type Unspecified